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Mayer KH, Peretti M, McBurnie MA, King D, Smith NX, Crawford P, Loo S, Sigal M, Gillespie S, Davis JA, Cahill S, Grasso C, Keuroghlian AS. Training Health Center Staff in the Provision of Culturally Responsive Care for Sexual and Gender Minority Patients: Results of a Randomized Controlled Trial. LGBT Health 2024; 11:131-142. [PMID: 38052073 DOI: 10.1089/lgbt.2022.0322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2023] Open
Abstract
Purpose: The study was designed to evaluate whether an educational intervention to train the health center (HC) staff to optimize care for sexual and gender minority (SGM) patients could improve documentation of sexual orientation and gender identity (SOGI) and increase preventive screenings. Methods: Twelve HCs were matched and randomized to either receive a tailored, multicomponent educational intervention or a 1-hour prerecorded webinar. Documentation of SGM status and clinical testing was measured through analysis of data that HCs report annually. Nonparametric statistics were used to assess associations between baseline HC characteristics and outcome measures. Results: The HCs were geographically, racially, and ethnically diverse. In all but one HC, <10% of the patients were identified as SGM. Intervention HCs underwent between 3 and 10 trainings, which were highly acceptable. In 2018, 9 of 12 HCs documented SO and 11 of 12 documented GI for at least 50% of their patients. Five of 6 intervention HCs increased SO documentation by 2020, compared to 3 of 6 control HCs (nonsignificant, NS). Five intervention HCs increased GI documentation, although generally by less than 10%, compared to 2 of the controls (NS). Intervention HCs tended to increase documentation of preventive services more than control HCs, but the changes were NS. Conclusions: An educational intervention designed to train the HC staff to provide culturally responsive services for SGM patients was found to be acceptable, with favorable, but nonsignificant changes. Further refinement of the intervention using a larger sample of HCs might demonstrate the effectiveness of this approach. Clinical trial registration #: NCT03554785.
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Affiliation(s)
- Kenneth H Mayer
- The Fenway Institute, Fenway Health, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School/Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Matteo Peretti
- The Fenway Institute, Fenway Health, Boston, Massachusetts, USA
| | - Mary Ann McBurnie
- Science Program Department, Kaiser Permanente Center for Health Research, Portland, Oregon, USA
| | - Dana King
- The Fenway Institute, Fenway Health, Boston, Massachusetts, USA
| | - Ning X Smith
- Science Program Department, Kaiser Permanente Center for Health Research, Portland, Oregon, USA
| | - Phillip Crawford
- Research Data Analytics Center, Kaiser Permanente Center for Health Research, Portland, Oregon, USA
| | - Stephanie Loo
- The Fenway Institute, Fenway Health, Boston, Massachusetts, USA
- Department of Health Law, Policy, and Management, School of Public Health, Boston University, Boston, Massachusetts, USA
| | - Maksim Sigal
- The Fenway Institute, Fenway Health, Boston, Massachusetts, USA
| | - Suzanne Gillespie
- Research Data Analytics Center, Kaiser Permanente Center for Health Research, Portland, Oregon, USA
| | - John A Davis
- Department of Medicine, University of California at San Francisco, San Francisco, California, USA
| | - Sean Cahill
- The Fenway Institute, Fenway Health, Boston, Massachusetts, USA
| | - Chris Grasso
- The Fenway Institute, Fenway Health, Boston, Massachusetts, USA
| | - Alex S Keuroghlian
- The Fenway Institute, Fenway Health, Boston, Massachusetts, USA
- Department of Psychiatry, Harvard Medical School/Massachusetts General Hospital, Boston, Massachusetts, USA
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Johnstone T, Thawanyarat K, Eggert GR, Navarro Y, Rowley MA, Lane M, Darrach H, Nazerali R, Morrison SD. Travel distance and national access to gender-affirming surgery. Surgery 2023; 174:1376-1383. [PMID: 37839968 DOI: 10.1016/j.surg.2023.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 08/17/2023] [Accepted: 09/05/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND Gender-affirming surgery is unequally distributed across the United States due to resource allocation, state-based regulations, and the availability of trained physicians. Many individuals seeking gender-affirming surgery travel vast distances to receive care. This study aims to quantify the distances that individuals travel to receive gender-affirming surgery based on procedure type and patient home-of-record location. METHODS Patients in the Optum Clinformatics Data Mart who underwent gender-affirming surgery were identified via Current Procedural Terminology codes. Data on patient demographics, procedural care, and location of patient and provider were collected. To be included, a patient had to meet diagnostic criteria to receive gender-affirming surgery and have a recorded surgical procedure reimbursed as part of gender-affirming surgery per the Centers for Medicare and Medicaid Services guidelines. Patients residing or receiving care outside the continental United States were excluded. Distances between the ZIP Code of each patient's home of record and the location where the gender-affirming surgery was performed were calculated via the Google Maps Distance Matrix API. Distance traveled for gender-affirming surgery by patient state and gender-affirming surgery procedure were determined. Multivariate linear regression analysis determined predictors of distance traveled for gender-affirming surgery, whereas multivariate logistic regression identified variables associated with an increased likelihood of out-of-state travel to gender-affirming surgery. RESULTS Across 86 million longitudinal patient records, the study population included 2,743 records corresponding to 1,735 patients who received gender-affirming surgery between January 2003 and June 2020. The median distance traveled for gender-affirming surgery was 191 miles (mean: 391.5), and 36.0% of patients traveled out of their state of residence. Every patient from West Virginia, Wyoming, South Dakota, Mississippi, and Delaware traveled out of state for gender-affirming surgery. Patients with homes of record in California (18.4%), Massachusetts (20.7%), and Oregon (19.0%) were the least likely to travel out-of-state for gender-affirming surgery out of states with more than 10 gender-affirming surgery encounters. The main predictors for out-of-state travel included both feminizing and masculinizing genital surgery, as well as an insurance coverage with increased provider options. Additionally, patients traveled shorter distances for gender-affirming surgery after the post-2014 Affordable Care Act expansion compared to pre-2014. CONCLUSION Patients receiving gender-affirming surgery in the United States travel great distances for their care, often receiving their care from out-of-state providers. Restrictive guidelines imposed by state laws on both the access to and provision of gender-affirming surgery compound the myriad of common difficulties that patients face. It is imperative to discuss potential factors that may mitigate these barriers for those who require gender-affirming surgery.
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Affiliation(s)
| | - Kometh Thawanyarat
- Medical College of Georgia at Augusta University, AU/UGA Medical Partnership, Athens, GA. http://www.twitter.com/tonythawanyarat
| | - Gina R Eggert
- Department of Molecular, Cellular, and Developmental Biology, University of California Santa Cruz, Santa Cruz, CA
| | - Yelissa Navarro
- Medical College of Georgia at Augusta University, AU/UGA Medical Partnership, Athens, GA
| | - Mallory A Rowley
- State University of New York, Upstate Medical University, Syracuse, NY
| | - Megan Lane
- Section of Plastic and Reconstructive Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Halley Darrach
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Rahim Nazerali
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA.
| | - Shane D Morrison
- Division of Plastic & Reconstructive Surgery, Department of Surgery, University of Washington, Seattle, WA
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Bruno J, Vedilago V, Goldhammer H, Campbell J, Keuroghlian AS. TransECHO: A National Tele-Education Program for Expanding Transgender and Gender Diverse Health Care. LGBT Health 2023; 10:456-462. [PMID: 36880963 DOI: 10.1089/lgbt.2022.0355] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023] Open
Abstract
Purpose: Few clinicians have received training to provide comprehensive primary care for transgender and gender diverse (TGD) people. This article describes the program design and evaluation outcomes of TransECHO, a national professional development program for training primary care teams on the provision of affirming integrated medical and behavioral health care for TGD people. TransECHO is based on Project ECHO (Extension for Community Healthcare Outcomes), a tele-education model that aims to reduce health disparities and increase access to specialty care in underserved areas. Methods: Between 2016 and 2020, TransECHO conducted 7 year-long cycles of monthly training sessions facilitated by expert faculty through videoconference technology. Primary care teams of medical and behavioral health providers from federally qualified health centers (HCs) and other community HCs across the United States engaged in didactic, case-based, and peer-to-peer learning. Participants completed monthly postsession satisfaction surveys and pre-post TransECHO surveys. Results: TransECHO trained 464 providers from 129 HCs in 35 U.S. states, Washington DC, and Puerto Rico. On satisfaction surveys, participants provided high scores for all items, including those related to enhanced knowledge, effectiveness of teaching methods, and intentions to apply knowledge and change practice. Compared with pre-ECHO survey responses, post-ECHO responses averaged higher self-efficacy and lower perceived barriers to providing TGD care. Conclusions: As the first Project ECHO on TGD care for U.S. HCs, TransECHO has helped to fill the gap in training on comprehensive primary care for TGD people.
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Affiliation(s)
- Jack Bruno
- Division of Education and Training, The Fenway Institute, Fenway Health, Boston, Massachusetts, USA
| | - Virginia Vedilago
- Division of Education and Training, The Fenway Institute, Fenway Health, Boston, Massachusetts, USA
| | - Hilary Goldhammer
- Division of Education and Training, The Fenway Institute, Fenway Health, Boston, Massachusetts, USA
| | - Juwan Campbell
- The Fenway Institute, Fenway Health, Boston, Massachusetts, USA
| | - Alex S Keuroghlian
- Division of Education and Training, The Fenway Institute, Fenway Health, Boston, Massachusetts, USA
- Division of Public and Community Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
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